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HomeMy WebLinkAbout0094 OLD TOWN ROAD Town of Barnstable Permit# o (0 ��� ��� PEr Expires li montiu from issue date DEC. egulatory Services Fee '.Z.�t � � Zp07 Thomas F.Geiler,Director T��j� ®F BARN Building Division �TTom�rry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address y �( G'/✓ �"" `' t � / �� Residential Value of Wo Minimum fee of$25.00 for work under$6000.00 Owner's Name&Addressor✓ , Contractor's Name /"�iy "�' � Telephone Number Home Improvement Contractor License#(if applicable) A�2 �p 3 Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance - Check one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of r000 ❑ Re-side Replacement Windows/doors/sliders. U-Value r (maximum.44) * hcre required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc, ***Note: Property Owner must sign Property Owner Letter of Permission. A cop of the Home Improvement Contractors License is required. 3IGNATURE: Norm xxpmtrg tevi'se061306 _... _..... ... . .. 7k e0wv1 w�uuealr/ o�✓�aauac�ivaeltb ` Board of Building Regulations and Sdandards HOME IMPROVEMENT CONTRACTOR Registration: 107723 ExP!ratroa 8%512008 1, t Y , Type DtE�A .. 1r � is MCCARTHY BU{:CDERS ' Brian McCarthy 32 Carver Road W.Yarmouth,MA 02673 Deputy Adrninistrator registration valid for individul use only License or g �{ before the expiration date. If found t'etun►to: Board of Building Regulations and.Sta>udards .l' One Ashburton place Rm 1.301 Boston,Ma.02108 INot valid ithout ignature 1 h� ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' www.mass gov/din ' Workers'Compensation Wur2nce Affidavit: Builders/Contractors/Eleetridans/Plumbers Applicant Information (/ Please Print Legibly Name(Business!organization/Individual): /I?CC' / �d/" Ig 4y Address: City/Statelzip: Z/V, 4 0 4)._Phone.#: Are you an employer?Check the appropriate boa: :Type of prof ect(required):. 1.❑ I am a employer with 4. [] I am a general contractor and I 6. ❑New construction . employees(full and/or part time).*• have hired the sub-contractors 2.❑ I am a'sole proprietor or partner- listed on the'attacbi d sheet. 7. ❑Remodeling ship and have no employees . These sub-contractors have 8. ❑Demolitions employees and have workers' �vorldng for me in any capacity. 9. ❑Budding addition 0 WOr1Cer8' c0 Msurance COIDp.incimance,$ 5. We are a corporation and its 10.[]Electrical repairs or additions re4aired] officers have exercised their 11. Plumbin repairs or additions ' '3.❑ I am a homeowner doing all-work . � . g p myself[No workers'comp. right df exemption per MGL 12.[]Roof repairs insurance.required.]t C. 152, §1(4),and we have no 13.f4 Other W employees.[Na workers comp.insurance required] *Any 4VHcant that checks box#1 must also fill out the section below showing their workers'compensation policy fi farmation. t Homeowncm. &o submit this affidavit indicating dry are doing all work and then hire outside contractors must submit a new affidavit indicating inch. tConhactors diet check this box must attached an additional sheet showing the name of the Suh-contractors and state whether arnot those entities have employees. i the sub-contractors have employees,theymust providb their workers'comp.policy number. I am an employer that is providing workers'compensation insurance fvr my employees. Below is the policy and job site' information. Insurance Company Nerne: Policy#or Self-ins.Lic.#: - - J Expiration Date: Job Site Address: l � City/State/zip: Attach a copy of the Workers'compensation policy declaration page'(shov►ing the policy number and expiration date). Fadure•to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penaltirm in the form of a STOP WORK,ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the,Office of _ Investigations of the IDIA for insurance coverage verification I do hereby certify under the airs and penalties of perjury that the information provided above is true and correct Si tare: Date: y <• ® _ Phone O Ykial use only. Do not write in this area, to be completed by,city or town,official City or Town: ' Permit/License# Issuing Authority(circle one): .1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• Town of Barnstable Regulatory Services BARNWi►iae,9�BI'E� Thomas F.Geiler,Director s639.� �� 0,39 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, X�[eV / (zz v z�L✓a�-�.�..o ,as Owner of the subject property hereby authorize A3A,c_yh: -Y17 c- Cc/-; to act on my behalf, in all matters relative to work authorized by this building permit application for: r (Address of Job) 15-1 o 7 Signdmre of Owner Date n f�( c Lz n l� yV L Print Mr de If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RM S D W N E RP ERM IS S ION Town of Barnstable ZHE Z Regulatory Services BARNSTABLE, ; Thomas F.Geiler,Director Y MASS. 161 a e Building Division rfD Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 vrww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 ` ^HOMEOWNER LICENSE EXEMPTION Please Print 's+n DATE: JOB LOCATION:. number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: µ city/town state zip code ti The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building,Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be'fequired to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Engmeering Dept.(3rd floor) Map Parcel Permit# House# 9 Date Issued /Q 7 Board of Health(3rd floor)-(8:15 -9:30/1:00-4:30) Fee O��J er-z Conservation Office(4th floor)(8:30- 9:36/ 1:00-2:00) Planni ept.(1st floor/School Admin. Bldg.) THE De ni 've an Approved by Planning Board 19 RARNSTAR X. MM TOWN OF BARNSTABLE 'f°"u�'�� Building Permit Applkationn rolect Street Address OLD w 1i I�� , Village ` S °Owner _Ly p )A- PAR (J©NN F_ Address ��A M� /Telep one 7 7,5- 7 D q rmit Request S{f DF_ W LLl N 4 F)`'LD t7� f' � `� G W ITS First Floor . square feet Second Floor square feet Construction Type vl�stimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No ' Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) Q Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# - Current Use Proposed Use Builder Infoor�rmation Name ,� Z �,� telephone Numbei- yS 7 9 y y /Address P• 0 • 0 X ) [ $ O icense- �_ C C C 1 L,9,t t MA • D a b3s_ . Home Improvement Contractor# unipullsit # ` NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE --T BUILDING PERMI DENIED F THE FOLLO ING REASON(S) T i' FOR OFFICIAL USE ONLY PERMIT NO. ` DATE ISSUED - to - ✓.•+, MAP/PARCEL NO. ADDRESS VILLAGE OWNER Y . DATE OF INSPECTION: ' t FOUNDATION - FRAME ! - INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL - + GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. WE r The Town of Barnstable • usxsru� , ' �m� Department of Health Safety and Environmental Services 10�" Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT - HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: F- S�N k-n L, ,.►9 Est.Cost 75 Address of Work: ' gy D L n 'TO LO N �ANON ti 5�0 2T 1— Owner's Name LEI n 1 A)FR G o p p E Date of Permit Application: 3©► 19 9 -7 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: � q 7 N a2S:!::1r Date Co rac or Nam Registration No. OR .�_._ nwnrr'c NnmP The Commontt•ealllt of Afassachuscttr %�:i1 '—i•�w D['pllrtntL'!tt Of Indttstrtal.4ccttic'nts I office a//A 7estlgatlons '1 1• iiw Ib1 .1 fig 1 • hOO f►ushttt„1tmr Street Bustutr. Alas. (1 111 W- Workers' Compensation Insurance Affidavit �J�Plic�int inforntatitiri• __- ...__._ pli se PRINT lebiiily r !/ ati n� cif' I n ❑ I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity am g an employer providin w king orkers' compensation form} employees wor o ❑�In this job. cninn•rni• n•ame- 9dtlrccc• cin nhnnc#• innirnnce rn noiica tt 1 am a sole proprietor. general contractor. or homeowner(circle oite) and have hired the contractors listed below who have the followin_ workers' compensation polices: cnmminv n•ttnc• •ttitirrtc• cin nhnnc#• incur-mrc rn nnlict # _ ennininy n91ny" - - •tdclrccc• rir�•• nhnnc#• incurnncc co. a _ Attach additio_nal sheet itneccs_iarv_`.::...._. F:1iIurc to secure cuvera¢c:is required under 6ection ZSA of A I G L 153 can lead to the imposition of cnminal penalties of a line up 10 51.500.UU andiur unc cars' imprisonment as evil as civil penalties in the form of a STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a cop} Of this staterncnt mac be forwarded to the Once of Investigations of the D1A for coverage verification. 1 do herchr ccrtifi•under the prints and penalties of perjury that the information provided above is true and cofrrect. Si^r atun �/ Date Print name Phone; :.'�ofGcialusc unls• do not t.•ritc in this area to be completed b�•cin•or town official -`.+ ' citi-or town: permit/license# rlBuilding Department ` ❑Uccnsing Board L t selectmen's Office I_ � check if imrnediate response is required ❑ ❑Health Department contact person: phone#: MOther P. �. Information and Instructions Massachusetts General Laws chapter 152 section '_5 requires all employers to provide workers' crnttpcnsation for th employees. As quoted from the "lay+ an eluphh ree is defined as every person in the service of another under am contract of hire. express or implied. oral or written. An einpinrer is defined as an individual. partnership, association. corporation or other legal entity, or any two or me the foregoinu enaaucd in a johifenterprise_and including the legal representatives of a deceased employer. or the receiver or trustee of an individual , partnership. association or other legal entity, employing employees. However ti owner of a dwelling house having not more than three apartments and who resides therein. or the occupant of the dwelling house of another who employs persons to do maintenance , construction or repair work on such dwelling_ he or on the __rounds or building appurtenant thereto shall not because of such employment be deemed to be an employ: MGL chanter 152 section 25 also states that even•state or local licensing ngenc,% sliall withhold the issuance or reneii•al of a license or permit to operate a business or to construct buildings in the commorm-calth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally. neither the commonwealth nor any of its political subdivisions shall enter into any contract for the perforniance of public work until acceptable evidence of compliance with the insurance requirements of this ct'�apter been presented to the contracting authority. Applicants >li ca nts I Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accideiits for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The town that the application for the permit or license is being requested. to the city or to pp affidavit should be returned . Should you have any questions regarding the "law' or if you are require Accidents. Slto _ '; not the Department of Industrial A q to obtain a workers' compensation policy. please call the Department at the number listed below. City or "I"owns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. K be sure to fill in the permit/iicense number which will be used as a reference number. The affidavits may be returnee the Department by mail or FAX unless other arrangements have been made. rite Office of Investigations would like to thank you in advance for you cooperation and should you have any questic please do not hesitate to _Live us a call. The Department's address. telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents _.. Office of Investigations 600 Washington Street Boston,Ma. 02111 fax #: (617) 727-7749 ' 06, 409 or 37� phone "Tr: (617) 721-4900 ext. 4 i anZ<;UmmUNWEALTH ur• mAbbALj1U8 115 CX Board of Banding Regulations and Standards Transaction No. One Ashburton Plate- Room 1301 Boston,Massachusetts 02108 Registration No. Application for Registration as a Effective Date Home Improvement Contractor or Subcontractor MGL Chapter 142A, CMR 780-6 Expiration Date FOR OFFICE USE ONLY Date L Name �'�FF�(L UA L-LF— V Print the name of the Judividual or business applying for the registration(not both) Z Mailing Address U `S( 67 y'S7_ 9 y91� A , Arse Code A Telephone Number 3 City( .Z��u.l� State �A . Zip �� �3S 4. Street Address(if different) B A I_T _g A, Ri::) �J Print street and Number(P.O.Boor not acceptable) City State Tip S. Applicant type: OIadividual ❑ DBA ❑ Partnership ❑Trust ❑ Private Corporation ❑ Public Corporation (See instructions on back regarding enclosing a city or towo registration under the DBA or"fictitious name"law-MGL c 110,ss S A 6) & (see instructions) `` 7. Number of Employee & Individual responsible for Home Improvement Contracts �/A LQEY V FFr SLY 9. Title of individual responsible for Home Improvement Contracts • _ I 12 Is the applicant claiming—ption fmm the registration fee? (See the insttuafoaa on.the back) ❑ ❑ If yes,include a onpy of a current Construction Supervisor license or motor vddde repair shop license or registration. Ye No IS. Registration fee enclosed:S Quaranty Fund fee encased;S Include two separate catifid drecb or money orders-one marked"Registration Fee°;one manned"Guaranty Fund". ALL APPLICANTS MUST INCLUDE A GUARANTY FUND FEE EVEN IF EXEMPT FROM THE REGIST'RA17ON FEE.See instructions an back for amount of fees. Make all certified cJzecks or money ord=payable to"Commonymaith of Massachusetts" pursuant to Massachusetts Gemxal Lives Chapter 62C section 49A,I amity order the peaaWm of perjury that I, to my bat knowledge and henry have Ned all state tax:returns and paW all state tsars required under lave n Si tuts of 1ppii4 or applicant's rep ratios Title held with applicant A false answer to any question in this application constitutes grounds for suspension or revocation of the applicant's registration. Ass P- T—"gyp` Parcel e t# ow Date Issued . - Fee J12.5 i � Engineering Dept. (3rd floor) House# - ' ' BARNSTABLE. MASS. 19 , 7Address TOWN OF BARNSTABLE Building Permit ApplicationPro' treet Q ge Owner L � � � Address Telephone Permit Request �T First Floor square feet Second Floor square feet Estimated Project Cost $ Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use _ 5'!1��� �,L�. �y /'� ,� Proposed Use Construction Type Commercial , Residential Dwelling Type: Single Family_ . Two Family Multi-Family Age of Existing Structure Basement Type: Finished / Historic House Unfinished / Old King's Highway d Number of Baths No.of Bedrooms 'Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool i)l) c) Attached Barn None i/�+ Sheds Other Builder Information Name / C� �� / Telephone Number 2 3 Address 3 2-- License# & 2 � L� , ? Home Improvement Contractor# /0 2 2& �) Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CON TRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO WwozV1OR- 4-IE-719 � SIGNATURE 4�WDATE � /C-�-)z l BUILDING PERMIT DENIED FOR THE FO LOWING REASON(S) FOR OFFICIAL USE ONLY j. irPERM N DATE SUED MAP/ AR EL NO. F ADD SS VILLAGE t F F f OWNE 1 DATE F I SPECTION: <• ' - FOUN ATION FRAME . INSULATION _ s FIREPLACE • ._ - _r � t � ,T - • ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH ► ' FINAL f { C GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t r j i ASSOCIATION PLAN NO. The Commonwealth of Alassachusctty Wait, -- Department of Industrial Accidents ` i. ! oxceol/ovest/9at/olls 600 Washington Street 4; ` .- ►'` Baston.Mass. 02111 Workers' Compensation Insurance Atftdavit Ap�Lcant Information• Please PRNTley_�� name location 7 ��� � "° •�- �� C - ' J clly . 1 am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity 1 am an emplover providing workers' compensation for my employees working on this job. company nant f address: ? — city: ► 1 nhonc#: incurince co poliey# 0 1 am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: company name: address: sill: phone#• incurtncc co policy# :��� _ `.' :.-r.•--•• _ - �.•tnrrr•.L.:,rrRs'=�'„',�.;"-�m;Hfr"5Fc''`%s.' -- •�r+a+rt��f• - .�:+�'f :?r-�••*±[*+��r.,.wq;.eg!��"':"."',� compam•name: - address: cil•• phone#* ipcur•Ince co policy# :Atiaeh additional sheet ittiecessa7�' `is}:':_.y s v�<<t:�4 J1 {'PY1 -• T�ld� �._.ul[-" ""` -�R _ ,ruo.tt�a. Failure to secure coverage as required under See tion 25A of 111GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand that a copy of this statement may be forwarded to the Office of Investigations of the D1A for coverage verification. I do hereby certi •finder the pair affd penalties ojpefyu •that ripe information provided above is true and comet. L� 3����� Signature �i Date , 22 Print name Phone# -2 75-(S S-J oRcial use oniv do not write in this area to be completed by city or town official + city or town: permit/license# Mudding Department Licensing Board O check if immediate response is required OSclectmen's Office [31lealtb Department ' contact person* phone#;. nUther Imued 3,95 PJA) f . : The Town of Barnstable S g Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Ralph Crosses Office: 508 790.6227 Building Commissionf F= 508 775-3344 For office use only Permit no Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal, demolition, or construction of an addition to any pm-existing owner occupied building containing at least one but not more than four dwelling units or to suuc=cs which are adjacent to such residence or building be done by registered contractors,with certain caption, along with other requirements. Type of Work: �" "t 0,�`C Fst Cost ` Address of Work: "/ �� �CT�V�l/ Di 0%mer.Name: Date of permit Application: 7 �� I hereby certify that: Registration is not required for the following rtason(s): Work excluded by law ob under S1,000 uilding not owner—pied Owner pulling own permit Notice is hereby given that: CONTRACTORS OWNERS PULLING THEIR OWN PERMIT OR DEAL-ING WITH DO NOT HAVE LESS TO THE FOR APPLICABLE HOME IMPROVEMENT' ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. 7 5ob Date Contractor name Registration No. OR ' owner's name . . � .. .... ,\ -- . � � �1' _. . _ ;s.:. {� .. 1�� - �Y . .. r �R _ _ [.' .. A:� .� VA . o� w� a� ac��a� � , 0 a r �, c '�gem, ; �,o,.